Choosing Wisely Manitoba is focused on projects where there is an opportunity, specific to Manitoba, to improve the appropriate use of diagnostic testing by reducing tests overwhelmingly shown by evidence to provide no benefit to a patient.

Appropriate Use of Vitamin D Deficiency Testing

Vitamin D (25(OH)D) deficiency testing in Manitoba has increased exponentially over the last eight years, from approximately 5,000 in 2006 to 50,000 completed tests in 2015/16. Evidence based guidelines advise against routine testing, however it is estimated that approximately 90% of these tests have been completed on patients without medical indication, representing up to $800,000 that could be redirected to other critical diagnostic areas.

CWM implemented new ordering criteria and a new requisition (supported by Choosing Wisely Canada and Manitoba Endocrinologists) in early 2016 with initial data already showing a significant improvement within only a month’s time. Manitoba continues to see a decrease in ordering of this test, which is improving service delivery for medically indicated and priority tests as well as making way for a redirection of resources to other diagnostic areas of need. Related clinical practice changes can be found here (Jan 2016).

Improving Preoperative Diagnostic Testing

Ophthalmology, Orthopedic and General Surgery account for 70% of unnecessary pre-op tests. Sustainable implementation of standardized, evidence-informed clinical practice guidelines will reduce unnecessary surgery delays, reduce patient inconvenience and discomfort and avoid stressful ‘false positive’ results that could potentially result in further unnecessary investigation. Approximately $400,000 can be re-purposed to more appropriate areas of health care from these high-volume surgical specialties alone.

Tissues for Disposal Only

Human tissues removed during a biopsy or surgical procedure are typically sent to a pathology laboratory for diagnostic examination and testing. Under the framework of Choosing Wisely Manitoba, and with the support of Orthopedic Surgeon and Clinical Champion, Dr. Eric Bohm, DSM conducted a retrospective review of approximately 300 orthopedic surgery cases (representing one surgeon’s annual caseload) to correlate pathology findings with the original diagnostic imaging report. As evidence and experts had suggested, the results of the review supported the case that pathology testing on tissues removed from the body during orthopedic procedures do not provide additional clinical data making the original diagnostic imaging report clinically sufficient. With no value added to patient care, these tissues are now recommended for exemption from requiring pathological review and instead recommended for immediate disposal. Diagnostic Services Manitoba has developed a Standard Operating Procedure which will be the basis for the Choosing Wisely Clinical Practice Change that will direct surgeons to mark these orthopedic tissues for immediate disposal.

It is estimated that reducing unnecessary pathology testing on orthopedic specimens alone could result in a potential savings of $10,000 annually. Reinvestment of these funds will be shared between DSM and the Winnipeg Regional Health Authority Surgery Program, allowing for additional diagnostics and procedures. DSM will add Manitoba data to the existing literature in support of this practice through a published paper that can help other jurisdictions implement similar processes. This project will also serve as a framework to reduce unnecessary pathological testing from other areas of surgery within Manitoba. Related clinical practice changes can be found here (November 2017, August 2017, July 2017, June 2017, June 2017).

Activated Partial Thromboplastic Time (aPTT)

The suboptimal utilization of aPTT testing has been identified as a prevalent problem across all health regions in Manitoba.  As part of Choosing Wisely Manitoba and as per the aPTT testing recommendations issued by Choosing Wisely Canada, DSM’s Hematology discipline provided direction and new guidelines for the ordering of aPTT testing. Following this clinical practice change in October 2015 aPTT test requests have decreased provincially by an estimated 20,000 per month. It is anticipated that more than $57,000 will be saved in supply costs, allowing reinvestment within other areas of Hematology. Related clinical practice changes can be found here (September 2015).

Resource Stewardship in Medical Curriculum

Resource stewardship is a central focus of the Choosing Wisely initiative and an important concept to reinforce early in medical education as its principles can be carried throughout a physician’s career. Funded through DSM’s Summer Studentship Program, a project to better emphasize this concept within the University of Manitoba’s undergraduate medical education program (UGME) was funded through DSM’s 2016 Summer Studentship program. Following a review of Manitoba’s pre-clerkship medical curriculum, a variety of learning materials, including readings, interactive lectures, team-based learning sessions and online modules were developed, incorporating Choosing Wisely Canada recommendations. The impact of these changes on students’ knowledge and attitudes regarding resource stewardship are currently being assessed following the 2016-2017 academic year. Article: DSM Funds Student Project to Integrate Resource Stewardship into Medical Curriculum

ESR and CRP Testing

C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) testing generally offer the same information on a patient, looking for evidence of inflammation in the body. Often, physicians order both of these at the same time, not understanding that they both provide the same information except in special circumstances.  In collaboration with Infectious Disease specialists and Rheumatologists, DSM has established that we can safely not provide both tests to general practitioners unless they have the approval of a Hematologist or Hematopathologist.   This has resulted in a 25% decrease in combined testing. In addition, since this test is not needed as a stat test, DSM was able to consolidate the number of sites where this test is performed, adding to province-wide efficiencies. Related clinical practice changes can be found here (September 2017 and July 2017).

Appropriate Use of FOBT

In the absence of a national Choosing Wisely recommendation on Fecal Occult Blood Testing (FOBT), CWMB has assumed a leadership role in engaging DSM and Gastroenterology specialists to conduct research and present the evidence on appropriate use for FOBT in our province. The guaiac FOBT was designed to detect hidden blood in stool, making it an effective screening tool for colorectal cancer screening. However, the test is also commonly used (off-label use) in hospitalized patients to detect gastrointestinal bleeding in the investigation of anemia. In March a practice change was issued to support the recommendation that use of the guaiac FOBT should be restricted to the approved indication of screening for colorectal cancer in asymptomatic patients and should not be performed on hospitalized patients for investigation of anemia. CWMB has adopted this as its first “made in Manitoba” recommendation and hopes to lead other provinces in moving toward enforcing the appropriate use of this test. Related clinical practice changes can be found here (February 2017).

Improving the Appropriate Use of MRI for Lower Back Pain

Lower back pain is very common and 50-90% of people will experience lower back pain at some time in their lives. Patients wanting to pursue all options for diagnosis, treatment and recovery, are large drivers of inappropriate MRI and other medical imaging. This unnecessary testing can lead to more tests and in some cases, patients undergo surgeries that they do not need. In the absence of red-flag symptoms, MRI is not recommended for lower back pain. Patient education materials have been developed as a first step in the pilot project taking place at Boundary Trails Health Centre. These materials will be further supported by clinical guidelines, a provincial roll-out, and additional public awareness. Further physician resources can be found here.

A Growing Momentum for Choosing Wisely

The Effective use of Blood and Blood Products and Imaging for lower back pain will be significant focuses for the upcoming fiscal year. Other current and future planned CWM projects include D-Dimer/Imaging for Deep Vein Thrombosis and pulmonary embolism, imaging for headache and head pain and fecal occult blood tests. Related clinical practice changes can be found here (May 2017, June 2017).

Work and collaboration continues with priority preoperative groups as well as within other pre-op specialties and within other medical disciplines to explore new Manitoba appropriate initiatives. Thanks to the support of Manitoba’s medical community more than 40 new champions and 20 new initiatives have been identified for further exploration.